Histopathology from the dissecting room: Are cadavers a ...

Teaching Anatomy

www.anatomy.org.tr
Received: March 6, 2015; Accepted: April 9, 2015

doi:10.2399/ana.14.048

Histopathology from the dissecting room:
Are cadavers a suitable source of educationally
useful histopathology specimens?

Andrew Wood1, Susan Whiten1, Jill McVee2, Jon Issberner1, David Jackson1, C. Simon Herrington3

1The School of Medicine, University of St Andrews, St Andrews, Fife, Scotland, United Kingdom
2Biomedical Sciences Building, University of St Andrews, St Andrews, Fife, Scotland, United Kingdom
3Division of Pathology, Edinburgh Cancer Research Centre, Institute of Genetics and Molecular Medicine, Western General Hospital,
University of Edinburgh, Edinburgh, United Kingdom

Abstract

Objectives: The requirement of the General Medical Council to ‘reduce factual overload’ has led to the development of
integrated curricula in which the knowledge base related to basic medical sciences has been greatly restricted. The time allo-
cated to pathology teaching in medical schools has been decreased. The challenge for educators is to introduce effective
methods of learning pathology into an integrated, student-centred curriculum. The aim of this study is to assess the tissue
derived from cadaveric material and report its potential for use in teaching histopathology.

Methods: We have previously reported how we use cadavers’ medical histories when introducing students to their ‘first patient’.
The medical histories of the seventeen cadavers that were dissected during one academic session were reviewed for evidence of
reported pathology. During dissection unexpected pathological findings were noted. Standard histological processing was car-
ried out on pathological tissue from the cadavers, a prosection and a specimen which was displayed in a museum pot. These
specimens were then assessed for educational value by an expert clinical histopathologist.

Results: We find that the availability of a real medical history combined with gross and microscopic pathology encourages inte-
gration of basic medical sciences and promotes the learning of both gross and microscopic pathology in the dissecting room.

Conclusion: The dissecting room provides ample material to introduce pathological concepts to undergraduate medical stu-
dents and this material is a valuable resource for teaching histopathology.

Keywords: dissection; gross anatomy education; histopathology; medical education; pathology education

Anatomy 2015;9(1):26–33 ©2015 Turkish Society of Anatomy and Clinical Anatomy (TSACA)

Introduction Digital or virtual pathology has been a central part of
a ‘quiet revolution’ in medical and science education.[6]
The study of pathology has played a pivotal role in The relatively recent introduction of digital pathology
developing an understanding of disease for at least three has had several beneficial educational consequences
millennia. Educational dissections of living and dead including improved student satisfaction, increased learn-
humans were performed and reported as early as 300 BC ing efficacy, increased student collaboration and per-
by both Herophilos of Alexandria (ca. 335-280 BC) and formance.[7,8] In addition instructor satisfaction is
Erasistratos (ca. 304-245 BC).[1-4] Two millennia would increased with virtual microscopy[9] and when questioned
pass before Johannes Muller (1801-1858) became one of students support an integrated approach utilizing digital
the first to use the microscope to analyse tissue. His stu- slides and teaching histopathology alongside histology.[10]
dent Rudolph Virchow used the microscope routinely in In addition, this technology potentially allows sparse
his work learning the title ’father of modern patholo- material to be used by increasing numbers of students.[11]
gy’.[5]

Histopathology from the dissecting room 27

Pathology and histopathology still lie at the core of duced a series of bespoke podcasts for medical education
medical knowledge today and are just as important in (www.e-pathpots.org.uk). Pathological changes discovered
other closely allied professional courses such as in the dissecting room can supplement these teaching
Dentistry and Veterinary Medicine. Medical curricula in methods and be used to link normal anatomy with disease
the United Kingdom have undergone fundamental and clinical practice,[28,29] the aim being to integrate pathol-
reforms since the first publication in 1993 of the General ogy teaching across disciplines.[30]
Medical Council recommendations in Tomorrow’s
Doctors, (GMC, 2009) and this process is on-going. It has been suggested that the discovery of pathology
such as cancer in the dissecting room can excite stu-
The profile of pathology as well as other basic medical dents[31] and Magrill et al.[32] report the ad hoc use of his-
sciences such as anatomy has been under pressure as the tology to investigate cancer in one cadaver. We have
number of hours devoted to discipline-based teaching has previously described a method of utilizing the dissecting
been progressively reduced[12] with the aim of limiting fac- room to teach gross pathology during anatomical dissec-
tual overload and to make way for the additional clinical tion[33] and this has been emulated by other authors.[34]
and communication skills training required by modern
medical graduates.[13,14] Experts in pathology recognise the The purpose of this study is to systematically describe
loss of visibility of tissue pathology in curricula.[15] the appearance of histopathology in a consecutive series
of 17 cadavers dissected during one academic session at
The study of pathology has been reduced although the School of Medicine, University of St Andrews. We
knowledge of pathological processes remains an essential aim to determine its potential usefulness, as judged by an
prerequisite to an understanding of medicine.[16] This expert pathologist, as a resource for the teaching of
change is due to increasing constraints on an overloaded histopathology to medical undergraduates. In addition,
curriculum but in part, also due to use of innovative teach- tissue samples were also retrieved and processed from
ing methods such as web resources and interactive com- one abdominal prosection and one ‘potted’ specimen to
puter assisted learning programs.[12] Concurrently there judge their usefulness for teaching and the effect of time
has been a move from discipline based courses to integrat- on the histological appearance of such specimens.
ed courses. Kumar et al.[17] suggest some 51% of schools
surveyed have some integration of systemic pathology and Materials and Methods
65% for clinical pathology. An unexpected consequence
of this change may include medical graduates failing to The cadavers consisted of 11 males and 6 females, with
considering pathology as a potential career[18–20] exacerbat- ages ranging from 68 to 92 years old. Each cadaver was
ing the diminishing visibility of the subject. In addition preserved by standard infusion with a Cambridge
there has been a decline in the use of the post mortem for Formulation Fixative 99% alcohol, formaldehyde, phenol
teaching, this despite the positive opinion of medical edu- and glycerol.
cators regarding the value of such examinations.[21,22]
Although some may raise reservations[23] most students Brief medical histories for each cadaver were obtained
generally regard post mortems positively.[24] from consultation with their General Practitioner and the
cause of death was derived from hospital notes and death
Burton[3] suggests many good reasons why pathology certificates. These medical histories were reviewed in
should be taught including, to promote the understand- order to identify likely pathology and the renal, respirato-
ing of the pathological basis of disease, to introduce the ry, gastrointestinal, cardiovascular and nervous systems
use of the language of medicine and to gain an under- were examined and examples of gross pathology noted.
standing of evidence based medicine. In addition, he sug- The abdominal prosection used as a source of tissue sam-
gests that pathology education allows students the ple was derived from a 97-year-old female; the cadaver
important opportunity to observe pathology as a subject had been in the department for 2 years and was preserved
and meet working pathologists. as described above. There was no available medical histo-
ry. The potted specimen of brain was taken from the
Given the changes in medical education described, University of St Andrews Medical School historical col-
every opportunity should be taken to promote pathology lection. No medical history or preservation information
education. Currently medical education utilizes a combi- was available for this specimen.
nation of traditional teaching methods such as lectures
and seminars as well as newer methods such as web based Prior to dissection relevant pathology was pho-
self-directed e-learning modules[25] and teaching resources tographed using a Nikon D40X SLR camera and then
such as image / audio archives and museum audio small representative samples of pathological tissue were
tours.[26,27] The Royal College of Pathologists have pro- fixed in formalin, processed and embedded in paraffin
wax. Standard 5 μm thick sections were cut and stained
with Haematoxylin and Eosin (H&E). Subsequently rep-

Anatomy • Volume 9 / Issue 1 / April 2015

28 Wood A et al.

resentative histopathology was photographed using an well preserved as was the spleen. Less well preserved
Olympus BX51 microscope and camera. included portions of the gastrointestinal tract and liver
which showed marked autolytic changes.
Results
Most cadavers yielded gross pathology. These
The results are presented in Table 1 and selected cases showed excellent preservation under histological exami-
discussed in detail below. In addition, of the normal tis- nation and yielded identifiable histopathology. We were
sue present in the biopsies, blood vessels and kidney were unable to retrieve useful specimens from several cadav-

Table 1
Results for the 17 cadavers, one prosection and one ‘potted’ specimen.

Cadaver, prosection Age Sex Pathology described Gross pathology Histopathology
or potted specimen in History seen on dissection retrieved
1 88 Wall of splenic artery
M Cerebrovascular disease, chronic Gallstones, splenic artery aneurysm aneurysm
2 83 renal failure, Alzheimer’s disease,
3 76 hypothyroidism, hypertension Pulmonary fibrosis
4 82
5 88 M Myocardial infarction, Pulmonary Pulmonary fibrosis, gout Frontal lobe glioblastoma
fibrosis, non-Hodgkin lymphoma, gout
6 82 None
7 87 M Glioblastoma, previous cerebrovascular Glioblastoma, old cerebrovascular
disease, osteoarthritis infarct None
8 73
9 85 M Ischaemic heart disease, pulmonary Abdominal aortic aneurysm Splenunculi
oedema, duodenal ulcer
10 88 Stomach MALToma
11 91 M Stroke, myocardial infarction, chronic Peritonitis, popliteal artery aneurysm
renal disease, aspiration pneumonia, Renal cyst
type II diabetes, ‘twisted bowel’
Carcinoma of head of
F Chronic obstructive pulmonary Splenunculi pancreas& liver metastasis,
disease, pneumonia, diverticulitis ascending cholangitis
Pulmonary fibrosis
F Metastatic gastric lymphoma, Hallux valgus, liver metastasis,
Acutely inflamed inguinal
hypertension, right hip osteoarthritis thickened stomach wall lymph nodes

and replacement, right cataract removal Squamous cell carcinoma
of unknown origin
M Mesenteric ischaemia, atrial fibrillation, Abdominal aortic aneurysm, renal Chondro-sarcoma of lung

cardiomyopathy, bladder cancer, diverticulitis cysts, renal stones, diverticulitis None

M Carcinoma of pancreas & liver Carcinoma of pancreas, None
metastasis, carcinomatosis, liver metastasis,
‘arthritis’ splenunculi Renal cancer, invasion of
renal vein, distant lung
F Osteoarthritis,pulmonary fibrosis, previous Pulmonary fibrosis, mastectomy scar metastasis, liver necrosis
None
breast cancer, right cataract removal Squamous cell carcinoma
of unknown origin
F Bronchopneumonia, ischaemic left leg Ischaemic left leg, Metastatic melanoma
osteoarthritis, myocardial infarction, osteoarthritis of knee
previous cervical carcinoma, dementia,
bilateral cataracts

12 74 M Extensive metastatic spread from Scoliosis, kyphosis,
13 86 unknown primary, polio, diverticulitis abdominal lymph nodes
14 87
15 90 M Ruptured abdominal aortic aneurysm, Ruptured abdominal aortic aneurysm,
lung cancer, hypertension lung mass, enlarged heart
16 92
F Myocardial infarction, gallstones, 15 cm long appendix, gallstones
17 68 ‘kidney disease’
Prosection 97
F Bronchopneumonia, ischaemic heart Right inguinal hernia, jaundiced
disease, pulmonary hypertension,
right cataract replacement

M Renal cancer, lung metastasis, Right renal mass, osteoarthritis
osteoarthritis, bilateral cataract
replacement

M Non-Hodgkin lymphoma, hypothyroidism General lymphadenopathy

F Unknown Retroperitoneal mass

Potted specimen Unknown Unknown Unknown Unknown

Anatomy • Volume 9 / Issue 1 / April 2015

Histopathology from the dissecting room 29

Figure 1. Malignant brain tumour with features consistent with a Figure 2. Non-Hodgkin lymphoma surrounding the gastro-oesophageal
glioblastoma. junction of cadaver 7. Neoplastic lymphoid cells infiltrate throughout the
muscle layers of the oesophageal / gastric wall.

ers due to problems attributable to fixation. A case by Cadaver 7 – Non-Hodgkin lymphoma
case description of interesting pathology is provided
below. The cause of death for this 87-year-old female was given
as metastatic gastric lymphoma. When the intra-abdom-
Cadaver 3 - Glioblastoma inal cavity was opened a hard mass was noted surround-
ing the gastro-oesophageal junction. A biopsy of this
This 76-year-old male died from the effects of a glioblas- area is shown in Figure 2. No involvement of lymph
toma. He had a previous history of cerebrovascular disease nodes or spleen was identified macroscopically. Given
and this condition was clearly visible on gross dissection of the morphological appearance and the pattern of organ
his brain. No tumour deposits were identified in any other involvement, these appearances are most in keeping with
organs. A section taken from the lesion identified in the a non-Hodgkin lymphoma of mucosa-associated lym-
brain (Figure 1) shows a malignant tumour with an phoid tissue (MALToma).
appearance consistent with a glioblastoma.
Cadaver 9 – Pancreatic carcinoma

This cadaver was an 85-year-old male who died from
metastatic pancreatic carcinoma. On dissection of the
abdominal cavity he had a pancreatic stent in situ, pass-
ing through a hard craggy mass in the head of the pan-
creas. A biopsy from this region is shown in Figure 3.
Also present were multiple intra-hepatic abscesses asso-
ciated with acute cholangitis.

Cadaver 16 – Renal carcinoma

This 92-year-old male died from a metastatic renal cell
carcinoma. Gross dissection revealed an obvious renal
tumour in the left kidney and pulmonary metastasis.
Histology of the renal lesions revealed an undifferentiat-
ed carcinoma (Figure 4).

Figure 3. Pancreatic adenocarcinoma invading muscle of the duode- Prosection – Retroperitoneal carcinoma
nal wall.
The prosection of a 97-year-old female was also exam-
ined and a large hard pale white tumour was noted in the

Anatomy • Volume 9 / Issue 1 / April 2015

30 Wood A et al.

Figure 4. Histopathological appearance of the renal carcinoma. Figure 5. Keratinising squamous cell carcinoma from the prosection.

left retroperitoneum spreading into the pelvic cavity. cation as one of several educational interventions aims to
Histological analysis of a biopsy confirmed a squamous effectively increase transfer of basic scientific knowl-
cell carcinoma (Figure 5). edge.[36]

Potted Specimen – Brain metastasis We have previously shown that cadaveric dissection
provides excellent opportunities to introduce and discuss
This potted specimen of brain showed multiple well cir- gross pathologies to undergraduate medical students,[33]
cumscribed pigmented metastatic deposits throughout providing a basis for detailed formal study of the disor-
the cerebral hemisphere and brainstem. On microscopic der later in the curriculum. In addition, surgical inter-
examination, the brain showed good preservation and a ventions (for example a pancreatic stent) and anatomical
deposit of a poorly differentiated malignant tumour. variations (e.g. long appendix) are common and provide
These macroscopic appearances and features are most in aids in teaching when attempting to bridge the perceived
keeping with metastatic malignant melanoma (Figure gap between preclinical sciences and clinical medicine.
6).

In most cadavers, both gross and microscopic pathol-
ogy were retrievable and in many cases the histology
revealed identifiable pathology and so allowed specific
diagnosis. Pathology was also identified in both the pro-
section and the potted specimen several years since their
initial preservation.

Discussion Figure 6. Multiple deposits of tumour in the potted specimen, a brain
slice, showing an appearance consistent with metastatic malignant
The Medical School at the University of St Andrews melanoma.
retains full body dissection and a notable part of our
teaching is the provision of a brief medical history in the
dissecting room. We encourage our students to see their
cadaver as “their first teacher”[35] not only of anatomy but
also of other medical sciences such as pathology.
Anatomical teaching commences in their first week of
student life and continues throughout their three year
undergraduate education at the University of St
Andrews. The central use of the cadaver in medical edu-

Anatomy • Volume 9 / Issue 1 / April 2015

Histopathology from the dissecting room 31

In this study, we have extended our previous findings on background reading about the pathology identi-
to show that the microscopic preservation of pathologi- fied in ‘their first teacher’.
cal changes in cadavers is excellent and provides addi-
tional educational material for teaching histopathology • Staff may predict common conditions and integrate
in an integrated curriculum. Chapman et al.[37] reported cases with virtual microscopy[42] to complement the
poor preservation of tissues derived from cadavers. gross pathology expected at dissection.
Although not all cadaveric tissue preservation is perfect
in our study, it resembles that found in post mortem his- These approaches have several aims. Principally, they
tology and it is certainly useful for teaching. are intended to promote student contact with pathology
and pathologists and to introduce the language and
In addition we have shown that older tissues from a processes of pathology which are currently lacking in our
prosection and a specimen in a museum pot remain a curriculum. For example, filling in a pathology request
useful resource for teaching several years after preserva- form introduces the student to written professional com-
tion. The histopathology described ranged from the munication and to the information required on a request
common to the rare and unexpected. Pathological con- form.
cepts such as invasion and distant metastasis are revealed
in the cadavers and provide an introduction to the patho- It is envisaged that students following up the cadav-
physiology of disease. eric biopsies and giving presentations on the pathology
identified will be introduced to research. This may be
Pathology has traditionally been formally taught via integrated with SSCs, form a basis for Clinico-
lectures, practical classes and clinico-pathological con- Histologic Conferences[43] or provide a basis for research
ferences. Integrating pathology into the core curriculum based seminars.[44] Pathology grand rounds in the dissect-
remains a challenge for medical educators.[38,39] ing room could be developed where students would pres-
Knowledge of the processes leading to a pathological ent the gross and microscopic pathology of their cadaver
diagnosis, such as biopsy, tissue preservation, tissue pro- to faculty and classmates.
cessing and tissue staining are lacking in undergraduate
medical education although it has been suggested by These novel approaches require flexibility. We have
some authors these should be part of the pathology core encouraged professional pathologists to become
curriculum.[40] involved in the dissecting room, but we are aware that
time constraints are ever present. Similarly histological
We are now exploring the following strategies for the processing of tissues requires time and resources and
teaching of histopathology alongside the gross patholo- there are financial consequences to consider when
gy present in the dissecting room; requesting repeated tissue processing.

• Encourage students to fill in pathology request forms We have no control over the pathology present in
requesting histological processing of pathology sam- each year’s cadavers although overall pathology is com-
ples. mon. Pathology archives are common in medicine and a
collaborative archive of cases in a wiki format is an
• Encourage students to ‘follow up’ biopsies taken dur- attractive option for further investigation.[45]
ing dissection[32] and give them the opportunity to meet
with pathologists to review slides, and if possible reach In addition, the reinforcement of pathology in our
a tissue diagnosis. We acknowledge that there is more curriculum increases the resources available for assess-
to histopathological diagnosis than a routine H & E ment. For example McMahon and Benbow[46] describe an
stain, part of the follow up may include the use of OSCE station based on death certification: in our situa-
immunohistochemistry to elucidate a definitive diag- tion OSCE stations could be created based on the cor-
nosis. For example lesions from cadavers 7, 9 and 16 rect completion of pathology request forms.
and the potted specimen may have benefited from fur-
ther investigation. We have shown that gross pathological material pres-
ent in the dissecting room can be used for teaching.[33]
• Develop clinico-pathological cases based upon the We have extended this finding in this present study to
histopathology retrieved during dissection and show that cadaver-derived material is of good enough
patient histories.[41] quality to be used in histopathology teaching and we
have discussed ways of utilizing this rich resource. We
• Develop Pathology Student Selected Components believe that the dissecting room remains a neglected
(SSC) based on the cadaveric pathology present and source of material which may be used to teach essential
use this to introduce the concept of ‘research’ based sciences in a modern integrated medical course.

Anatomy • Volume 9 / Issue 1 / April 2015

32 Wood A et al.

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Online available at: Correspondence to: Andrew Wood, MBChB
www.anatomy.org.tr Department of Laboratory Medicine (Pathology), Royal Infirmary of Edinburgh,
doi:10.2399/ana.14.048 51, Little France Crescent, Little France, Edinburgh EH16 4SA, UK
Phone: +44 0131 536 7138
QR code: e-mail: [email protected]

Conflict of interest statement: No conflicts declared.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported (CC BY-NC-
ND3.0) Licence (http://creativecommons.org/licenses/by-nc-nd/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. Please cite this article as: Wood A, Whiten S, McVee J, Issberner J, Jackson D, Herrington CS.
Histopathology from the dissecting room: Are cadavers a suitable source of educationally useful histopathology specimens? Anatomy 2015;9(1):26–33.

Anatomy • Volume 9 / Issue 1 / April 2015